Thoughts on the Bulletin.

Because daguerreotype photographs are usually reversed laterally from actuality, images of W.T.G. Morton falsely suggest that he sometimes changed the side of the part in his hair. Because of daguerreotype image reversal, a statue of Apollo in the Ether Dome at the Massachusetts General Hospital appears to have been moved for the 50th anniversary of Ether Day. Ether anesthesia was announced in the Boston Medical and Surgical Journal in 1846.1,2 The fiftieth anniversary of the event was celebrated in the same journal.3 Two images of William Thomas Green Morton in the 1896 issue are discrepant.3 As copied in Figure 1, Morton is first shown with his hair parted on the right side of his head. In the next image, his hair is shown parted on the opposite side. An image of someone of Morton’s importance should be remembered as accurately as possible, and the first image is inverted from right to left. The explanation for the inversion is straightforward.4 The reversed Morton is copied from a daguerreotype photograph. Patented by Louis Daguerre in 1839, those tive one (with bright areas shown as black). The negative is converted into a positive image in two chemical steps. First, elemental mercury vapor dissolves into (amalgamates with) the silver granules, rendering them bright. Second, the remaining silver iodide the Massachusetts General Hospital. The operating table is near center stage. The sunlight comes from the south, where the theater seating is located; the camera is among the seats, looking north to the crowded stage. A statue of Apollo was donated to the MGH in 1845 and appears to be located to the right of the photographer, to the east of the actors. However, the photograph is laterally reversed. In reality, Apollo, still guarding the Ether Dome today, stands with right foot forward. The stance appears reversed in the 1847 daguerreotype. A quiver of arrows should be just lateral to the right leg. There is no quiver near the apparent right leg of the statue. In the daguerreotype, Morton’s waistcoat seems to incorrectly button rightover-left. Those clues to lateral reversal are subtle, and Apollo was probably moved for the photograph of 1896, which is not a reversed image. Apollo’s image of 1896, with quiver to his right and with left arm held out for the bow, appears as it does in reality. However, he is located on the wrong side of the stage. Since the photograph of 1896, Apollo has been repositioned to his original place in the historic room. Accordingly, he now faces away and points away from the nearest wall. The 1847 daguerreotype is sometimes said to represent the Ether Day scene of October 16, 1846. Instead, the staged photograph may have been intended to commemorate the first capital (life-threatening) Fig. 1. Images of W.T.G. Morton from the semi-centennial commemoration of Ether Day published in the Boston Med Surg J in 1896.3 The hair part indicates that the first image, that on the left, is laterally inverted. The inversion is also evident from the right-over-left buttoning of the waistcoat. photographs were usually inverted laterally (unless the apparatus included a mirror). In the daguerreotype process, an image is focused onto a film of metallic silver, the surface of which had been rendered light sensitive by reaction with iodine vapor. Exposure to light converts the silver iodide coating to relatively dark silver granules. Accordingly, the photograph is first a negaFig. 2. The Ether Dome restored in 1896 to as it supposedly was in 1846.3 Apollo is to the right of the photographer. An arrow quiver is near his right foot, which is forward of the left foot. Contrary to artistic dictates, he faces the nearest wall. is darkened with “hypo,” sodium hyposulfite. After the so-developed silver film is righted from top to bottom, the image appears as if the observer were looking at the subject with the aid of a silver mirror. The 1896 commemoration also includes an 1896 photograph of the Ether Dome, the operating theater in which anesthesia history was made (Figure 2). The room of the 1896 image is said to have been restored to appear as it did in 1846. The room of the 1896 image is said to have been restored to appear as it did in 1846. However, the restorers may have been fooled by an 1847 daguerreotype (Figure 3). Accordingly, an Ether Dome statue of Apollo was displaced to the wrong side of the stage. The 1847 daguerreotype of the Ether Dome was commissioned by surgeon John Collins Warren.4 The magnificent image, the first photograph of an operating theater, now hangs in the Ether Dome building of Continued on Page 8 8 buLLeTIn oF AneSTHeSIA HISToRY morton. . . Continued from Page 7 operation aided by inhaled ether. This was a right above-the-knee amputation performed Fig. 3. Daguerreotype commissioned by John Collins Warren in 1847. The archer Apollo appears to be to the right of the unseen photographer (Apollo is to the immediate right of the inset), but the quiver is not near the apparent right foot, and the apparent left foot is forward. Hence, the image is laterally reversed. The correct stance is shown in the inset in the right upper corner. The inset comes from a modern photograph of the statue. The hands of Warren rest on the apparent left leg (but actually the right, corresponding to the diseased right leg of Alice Mohan). The anesthetizer is probably Jonathan Mason Warren. by George Hayward on Alice Mohan with the permission of Warren for Morton to provide inhaled anesthesia. At that event, on November 7, 1846, Morton publically revealed that the active ingredient of his patent medicine was diethyl ether. However, if Warren intended to preserve a likeness of November 7, he nonetheless effected some displacements. Warren, not Hayward, rests his hands upon the leg. The anesthetizer is not Morton. The anesthetizer in the photograph is probably Jonathan Mason Warren, son of the chief of surgery. J.M. Warren is not holding a glass Morton inhaler. He holds a simple sponge, which he had introduced as a less-cumbersome alternative to Morton’s device.5 J.M. Warren later credited himself with “the first successful operation under ether which was done in private practice.”6 In the posed publicity shot of Figure 3, Morton has been displaced by the Warrens. In one sense or another, the “parts” of many figures from the mid-nineteenth century may need to be re-examined. References 1. Bigelow HJ. Insensibility during surgical operations induced by inhalation. Boston Med Surg J. 1846;35:309-317. 2. Warren JC. Inhalation of ethereal vapor for the prevention of pain in surgical operations. Boston Med Surg J. 1846;35:376-379. 3. Davis RT, Ashhurst J Jr, Cheever DW, Reynolds JP, McBurney C, Mitchell SW. Semi-centennial of anesthesia. Boston Med Surg J. 1896;135:377-386. 4. Haridas RP. Photographs of early ether anesthesia in Boston: the Daguerreotypes of Albert Southworth and Josiah Hawes. Anesthesiology. 2010;113:13-26. 5. Warren JC. Etherization; with Surgical Remarks. Boston: William D. Ticknor and Company; 1848:9. 6. Warren JM. Surgical Observations, with Cases and Operations. New York: William Wood and Company; 1867:616. buLLeTIn oF AneSTHeSIA HISToRY 9 From Bench to Bedside: Claude Bernard, Henry K. Beecher, MD, and Science in Anesthesia Matthew L. Edwards, AB Medical Student, University of Texas Medical Branch at Galveston, Galveston, Texas Disclosure The 2009 Paul M. Wood Fellowship program at the Wood Library-Museum of Anesthesiology funded this research. manuscript versions presented at Cme meetings The 17th Annual Spring Meeting of the Anesthesia History Association and UT Southwestern Medical Center, April 29, 2011, Grapevine, TX. The 18th Annual Spring Meeting of the Anesthesia History Association and Kansas University Medical Center, May 4, 2012, Kansas City, KS. Abstract Success with the medical management of pain grew tremendously after William Thomas Green Morton’s successful demonstration of surgical anesthesia in 1846. Henry K. Beecher’s clinical and experimental contributions to anesthesia during and after World War II had a profound impact on how clinicians and experimentalists study human populations in medicine. Beecher found that pain research required human subjects because pain was different for each individual. Nearly 100 years before Beecher, Claude Bernard similarly considered the complexity and uniqueness of human research subjects. Bernard and Beecher both preferred animal subjects in research when appropriate, but suggested that studies involving some mental, bodily, and cognitive processes required human subjects. Although Beecher and Bernard’s lives did not overlap, these two menSuccess with the medical management of pain grew tremendously after William Thomas Green Morton’s successful demonstration of surgical anesthesia in 1846. Henry K. Beecher’s clinical and experimental contributions to anesthesia during and after World War II had a profound impact on how clinicians and experimentalists study human populations in medicine. Beecher found that pain research required human subjects because pain was different for each individual. Nearly 100 years before Beecher, Claude Bernard similarly considered the complexity and uniqueness of human research subjects. Bernard and Beecher both preferred animal subjects in research when appropriate, but suggested that studies involving some mental, bodily, and cognitive processes required human subjects. Although Beecher and Bernard’s lives did not overlap, these two men similarly confronted the issues of complexity in human and animal research, particularly in those phenomena involving higher cognitive functions. Introduction Anesthesia’s clinical importance was widely recognized after William Thomas Green Morton’s successful demonstration of surgical anesthesia with ether in 1846.1 Nearly a century passed, however, before anesthesia gained the scientific basis needed for its development as a medical specialty.2 Dr. Henry K. Beecher’s [1904-1976] clinical and experimental contributions during the decades following World War II helped anesthesia develop an enduring scientific foundation. Although Beecher’s work spanned experimental physiology, pharmacology, and medical ethics, he is perhaps best known among physicians for his landmark study of differences in narcotic requirements between soldiers and civilians. Beecher’s study of pain among soldiers and civilians was important for several reasons. He found that the response to pain and suffering in humans varied across individuals and depended on an individual’s biological, psychological, cognitive, and social environment.3 This finding led Beecher to conclude that human subjects were necessary for experiments in medicine, especially “when the desired ends cannot be obtained in other ways, as through experimentation in animals.”4 Yet Beecher was not the first physician-scientist to consider the challenge of human and animal subjects in research. Nearly 100 years before, French experimental physiologist Claude Bernard [1813-1878] similarly considered the significance of living organisms for research and was one of the first scientists to advocate scientific method in biology. Bernard and Beecher both urged the use of animals in research when appropriate, yet understood that studies involving complex cognitive processes required human subjects. Their shared interests in physiology and anesthesia led to similar, historically significant views on human and animal subjects in medical research. Claude bernard and experimental Research Bernard conducted a number of basic research studies in anesthesia as early as 1855.5 He found that morphine administered before anesthesia reduced the amount of inhalation anesthesia needed. Bernard was also the first scientist to study curare and suggest its usefulness in neuromuscular blockade.5 More importantly, Bernard’s curare studies changed the direction of contemporary medical thought on the actions of drugs. At the time, physicians and experimentalists believed that drugs exerted a general influence on an individual. Bernard’s curare studies, however, found that drugs operated at “strictly localized and well-defined sites” of action.6,7 Claude Bernard is often credited as the “father of experimental physiology” because of his work in establishing physiology as a science.8 Bernard’s interest in physiology began early in his career when he studied the physiologic effects of curare, its mechanism of action, and its effects on the nervous system under the famous physiologist Francois Magendie.5 Bernard’s seminal publication in 1865, An Introduction to the Study of Experimental Medicine,10 laid the framework for a laboratory-based medical science at a time when medical knowledge was dominated by clinical observation.6 Although Bernard endorsed an experimental method for biological research, a majority of his contemporaries did not.9 These scientists believed that organisms possessed “vital forces” that acted independently of their physical and chemical properties.9,10 This notion of “vitalism” was at direct odds with the principle of determinism, which Bernard actively sought to promote in experimental medicine. In biological science, determinism refers to “a theory for which natural, psychological, and social phenomena are causally determined by preceding events or natural laws.11 Bernard understood that although outside factors affect outcomes in research, medical science could nonetheless predict and influence the behavior of organisms by understanding their initial conditions and the laws that govern them.10 The lynchpin of Bernard’s Introduction is the experimental physiology illustrated by concepts from his own research.6,9,10 His concept of the milieu intérieur (i.e., internal environment or homeostasis) held that organisms could regulate their bodies to maintain internal stability despite variations in external conditions.9,10 In discovering the glycogenic function of the liver, Bernard reasoned that organisms could respond with indifference to their environment. This principle was not only important for endocrine regulation, but also for experimental research. Indifference to the external environment suggested that “invariable conditions” (or controlled environments) were inherently more difficult in studies of higher organisms.9,10 Thus, for Bernard, Continued on Page 10 10 buLLeTIn oF AneSTHeSIA HISToRY the goals of research should be qualitative rather than quantitative understanding, and medicine should strive to understand differences between individuals as “special cases under a general law.”9,10 Bernard’s prejudice for qualitative experiment was rooted in his quest for physiological principles, not merely basic description and measurement of observations. For Bernard, scientific determinism meant that animal physiology studies were entirely applicable to humans. He argued that the use of statistics was insufficient for establishing a science because it did not account for nonquantifiable differences among individuals.9,10 This skepticism of statistics was not at all uncommon of 19th century science; it took several decades after Bernard’s death for statistics, or “mathematical medicine” as it was known, to gain enough sophistication to properly address data aggregated from multiple individuals in research.8-12 As an experimentalist, Bernard preferred case studies involving individual circumstances “rooted in rigorous, experimentally derived, and deterministic phenomena.”9 Scholars have generally agreed that Bernard believed that physicians needed certainty about whether a patient’s health would progress—certainty that could only be afforded through absolute laws, which required scientific determinism.9,10 According to Bernard, statistics could be useful in studying the efficacy of medical treatment (e.g., pain relief) but would likely mislead experimental physiology.12 Ultimately, Bernard viewed statistics as unnecessary when physicians and scientists understood the mechanisms and underpinnings of disease and pathology.12 Bernard believed that medical research required living beings, but recommended studying animal subjects before human subjects. Although he reasoned that all animals could be used for scientific investigation because the same principles and laws governed all living species, he conceded that experiments with human subjects would be most applicable to humans.10 More importantly, Bernard stated that “from a physiological point of view, experimental study of sense organs and cerebral functions must be made on man, on the one hand, because man is higher than the animals by faculties which animals lack.”10 Thus, Bernard understood that the study of cognitive phenomena in man required human subjects to understand behavior. Science. . . Continued from Page 5 Henry K. beecher and the Reaction